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.J a �N MM/DD/YY os.• °o Body Art Inspection Report Date( County of San Joaquin County,Environmental Health Department SZ13�S f < 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number 1: (209)468-3420 www.sioov.org/ehd I, `.. Permit Type V 4G%FORe��.. acility,Name Address City Zip Code CT , �c�Vi SA�on (Do -Lo N.PoI,441 , Avs- 4vJ&on San JOAIL411A Permit/Registration Holder Name Permit Exp.Date Total Time Inspection Type Li X h :&u 34 y u. (o NO/ RISK FACTORS AND INTERVENTIONS Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. In=In Compliance Out=Not in Compliance N/0=Not Observed N/A=Not Applicable COS=Corrected On Site �x "'" "F r TATTOO'AND`PERMANENT COSMETICS MACHINE '"' CLEANING%1ND;STERILIZAIlON " . ,, .'dtrr= cos y SAFETI(AND SANITATION * 1. Autoclave is approved and effective-passed ❑ ❑ jh) /0 18. Safe machine designN/ inte rator test 0 2. Process of cleaning,labeling,packaging and /0 19. Machines cleaned and disinfected betweensterliziin items correct) clients I LO 3. Autoclave loaded correctly/packages allowed to /0 20. Parts replaced between clients-grommets,N/A d elastic bands,etc. /0 4. Integrators used/monthly spore test/log PRESE�V6yEmyNTINO CR..dSy.S yCONTAMINATION'11 El A }y t NIA maintained 5. Decontamination/sanitation area separate and ❑ In N/0 21. Workstation/procedure area decontaminated /A supplied* /A ❑ ❑ In 0 6. Invoices and log kept for disposable,pre- ❑ NIO 22. Chemical disinfectant used ❑ 11N/A sterilized equipment,backupsupplies available* /A Chemical used: DA(- - In N/0 7. Sharps containers supplied,labeled,used and In N10 23. Disinfectant used sufficient contact tim Wet 11 N/A disposed of correctly101 /A contact time provided: t7 i nu�Q El In 8. Jewelry,tattoo and piercing equipment-storage ❑ ❑ I N/0 24. Barriers available and used as part of ❑ ❑ N/A and use /A procedure rc N!0 25. Products applied to skin are single ❑ ' EI PRACTITIONER HEALTH AND HYGIENE N/A useldis ensed ase tical) ri /0 9. No eating,drinking or smoking-clean clothes ❑ ❑ I N!0 26. Storage of inks,pigments,needles,tubes,etc., ❑ ❑ /A N/A Ino10. Hands washed effectively and timely In N/0 27. Jewelry,Inks,Needles etc approved and used N/A ❑ /A ❑ El In N/0 11. Handwashing facilities properly supplied and n NIO 28. Cross-contamination avoided during all phases A accessible,warm potable water* N/A of procedure In N/0 12. Personal protective equipment available and k BEST;BUSINE§S PRACTICES11, t ' " N/A used,eyewash station available* 11 ❑ 7 f `" r TA ' # ,,s 1CU#STOMERS/CLf.E�t�Na S,pt I N/0 29. Areas separated/no living or sleeping El 0 � tt► fsN/Aquarters/no animals In 10 13. Branding is completed with no other customers in ❑ ❑ In N10 30. Floors and walls clean and in good repair, ❑ N/A rocedure area N/A adequate light In !0 14. Customers eighteen(18)years of age or older ❑ ❑ �I fi" 0 31. Workstation,surfaces,including Chairs,,etc.in ❑ ❑ / �N A good repair,trash removed frequently* NIO 15. Skin prepared for procedure. ❑ 0 In N/0 32. Permitlregistration and required signs posted* ❑ N/A N/A In N/0 16. Client records available-Consent form& ❑ In N10 33. IPCP and employee training records and N/A questionnaire N/A Hepatitis B vaccination status present In N/0 17. Aftercare instructions given to client In 34 Restrooms available,stocked* ❑ N/A Received by(Print): J 2'e IP'2 Received by(Signature): Phone: Specialist(Print): Specialist(Signature): Phone: ❑ This report is an Official Notice of Violation.Corrections must be completed in the time specified. A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Pagel of I